Improving Oral Health Together

Transcription

1 Improving Oral Health Together An Oral Health and Dental Service Improvement Plan for Abertawe Bro Morgannwg University Health Board Reducing Inn Oral Reduced inequities A five year vision

2 Contents: Foreword 3 Executive Summary 4 Glossary of Terms 6 Action 1: Developing a Local Oral Health Plan 7 Action 2: Supporting the delivery of the Local Oral Health Plan 21 Action 3: Designed to Smile and Healthy Schools Programmes 23 Action 4: Cancer Networks 26 Action 5: Special Care Dentistry Implementation Plan 29 Action 6: Data on the number of children who receive dental treatment under GA 32 Action 7: Waiting lists for vulnerable patients 35 Action 8: Referral and Care Pathways 37 Action 9: Working with PGMDE regarding Postgraduate Dental Training 40 Action 10: Working with PGMDE regarding Tobacco Control Action Plans 42 Action 11: Improve Adult Mouth Care for Adult Patients in Hospital 43 Action 12: Primary Care Dental issues linked to the Annual Quality Statement 46 Action 13: Occupational Health Programme for General Dental Practices 49 Action 14: Oral Health input into pre-registration nurse training programmes 51 Action 15: Promotion of national oral health campaigns 54 Action 16: Integration of oral health into health and social care plans 55 Action 17: Management of primary care dental services 57 Action 18: Dental Domiciliary Care 61 Action 19: Developing alternative patterns of care 64 Action 20: Specialist dental services in primary, community and secondary care 66 2 Abertawe Bro Morgannwg University Health Board

3 Foreword On 18 March 2013, the Welsh Government (WG) released a national Oral Health Plan for Wales. In response to this the Health Board must develop a local oral health plan, indicating how it will achieve the actions set by the Welsh Government. This Local Oral Health Plan (LOHP) outlines an agenda for improving oral health and reducing oral health inequalities in Abertawe Bro Morgannwg University (ABMU) Health Board over the next five years. Prevention is at the heart of this plan. Reducing the risk factors that lead to oral disease is only possible if the delivery of dental services and oral health improvement programmes are oriented towards primary health care and prevention. Since the inception of ABMU Health Board in 2010 the Board has worked to bring together the three former Local Health Boards of Swansea, Neath Port Talbot and Bridgend, and considerable work has already been undertaken to bring together the service delivery for primary, secondary and community dental services. ABMU Health Board has established a number of Managed Clinical Networks and working groups to plan and deliver effective dental services. We do however recognise that there is further work to be undertaken and to achieve our aims change is required. The skills, experience, and dedication of the dental workforce across primary, secondary and community services are, and will remain, a vital resource upon which we will need to work with to achieve that change. Oral health is an intrinsic part of general health and wellbeing. One of our major goals in implementing this plan must be to help people take responsibility for ensuring their own good oral health. There remain significant differences between individuals with the best and worst oral health in ABMU. We must improve the health of everyone in our area and pay particular attention to the young and vulnerable groups and seek to reduce inequalities. Services must deliver modern prevention orientated NHS dental services resulting in high quality care being delivered in the most appropriate setting. We must also prioritise dental care for the most vulnerable. In developing this plan we have consulted with professional groups, neighbouring Health Boards and Local Authority colleagues. And as part of the City and County of Swansea s designated Healthy City status an Integrated Impact Screening Assessment has been undertaken on the plan to ensure the actions identified are as robust as possible in meeting the needs of the resident population. I commend to you the ABMU Health Board Oral Health Plan Paul Stauber Director of Planning 3 Abertawe Bro Morgannwg University Health Board

4 Executive Summary In responding to the Welsh Government (WG) National Oral Health Plan for Wales, Abertawe Bro Morgannwg University (ABMU) Health Board has produced a Local Oral Health Plan which responds to the 20 actions set out by Welsh Government. We recognise that we need to enable patients to take responsibility for their own oral health whilst supporting the most vulnerable groups to access high quality and effective services. Oral health is an intrinsic part of health and wellbeing. Currently we know that: 64% of the ABMU resident population attended a NHS dentist at least once in the 24 month period between April 2011 and March 2013, compared to 53% across Wales. The average distance travelled to see a dentist was 5 kilometres 88% of 6 to 17 year olds attended the dentist at least once between April 2011 and March 2013 We need to reduce the levels and burden of decay at ages 5 and 12 amongst the most deprived groups of patients by 2020 In 2011/12 the children living in the most deprived areas of the Health Board had an average dmft (decayed, missing, filled teeth) of 2.48 and a %dmft of 58.3% which is higher than the Welsh targets for this group. Whilst the situation has been improving there remains considerable room for improvement On average across Wales in a class of 30 five year olds, four children would have experienced dental pain in the last 12 months The Health Board, through developing the Oral Health Plan has identified a number of key priority areas to progress on over the next five years, which we hope will go some way to address the health inequalities and will enable the resident population to take responsibility for maintaining good oral health. 1. Access to urgent dental care during the working day We need to improve access to NHS dental services for patients who have an urgent dental need and who do not see a dentist on a regular basis for their ongoing dental care. Improved access for patients with an urgent need during the working day should reduce the patient contacts currently being reported by GPs, GP Out of Hours services and the Accident and Emergency Department. 2. Dental Out of Hours Services Work has already begun to look at a new model for dental Out of Hours services for those patients who have an urgent dental need. It is important for the Health Board to differentiate between an urgent dental need and a dental emergency where the patient needs to be seen in the Accident and Emergency Department. The new model will need to be supported by a patient education programme to ensure that patients are able to access the correct service. 3. Domiciliary Dental Services A review of domiciliary dental services has already been undertaken by Public Health Wales. The Health Board now needs to implement the revised service model to ensure that all patients requiring the service have access to a model of care delivered to a consistent standard, and that there is sufficient capacity in the service model to meet the clinical needs of patients. 4 Abertawe Bro Morgannwg University Health Board

5 4. Oral Cancer Due to the patient demographics of the Health Board area we already know that the incidence of oral cancer is forecast to continue to increase over the next 10 years. The Health Board needs to review the current service model for these patients to ensure that the Referral to Treatment Times (RTT) are adhered to and that the service model is capable of delivering against the short term anticipated growth in demand whilst planning a future service model. 5. Developing Dentists with Enhanced Skills Work has already begun to support the local recognition of dentists with enhanced skills in orthodontics and endodontics. In considering all of its service models and the associated workforce to deliver them, the Health Board will need to consider how dentists with enhanced skills can be appropriately supported to deliver against the organisations objectives for providing safe and effective dental services. 6. Orthodontics Considerable work has already been undertaken through the established Managed Clinical Network to develop a patient pathway that includes working with Dentists with Enhanced Skills (DES) and establishing a referral pathway. Demand for orthodontic services in specialist practices remains high and therefore the Health Board needs to continue to consider this as a priority area. 7. Children s General Anaesthetic (GA) Service Pathway A revised service model is being developed for implementation from January Work is ongoing to consider the ability to support the new model with a Paediatric DES which would include robust treatment planning of children referred into the service and to ensure an overall reduction in the number of general anaesthetics for children aged Designed to Smile (D2S) & Community Dental Services The Health Board will continue to support the D2S programme linking to data collected as part of the child GA service to identify schools within target areas. The development of the Community Dental Service will remain a priority for the Health Board to ensure that the outcomes of the Public Health Wales review are implemented. 9. Prison Dental Services The Health Board has the responsibility for the provision of dental services at Her Majesty s Prison Swansea. The current contract was established prior to the prison becoming a remand prison which has seen an increased demand in dental services. 10. Quality & Safety Underpinning all of the work undertaken in dental services across primary, community and secondary care, quality and safety is paramount in giving assurance to the Board that all of our dental services are fit for purpose. There is already a significant governance framework in place which we will continue to review to ensure that all services meet local and national standards, regardless of the setting in which they are delivered. 5 Abertawe Bro Morgannwg University Health Board

6 Glossary of Terms A ABMU - Abertawe Bro Morgannwg University Health Board AMD Associate Medical Director C CDS Community Dental Service CS Conscious Sedation D D2S Designed to Smile Dmft decayed, missing, filled teeth DES Dentist with Enhanced Skills DSPG Dental Strategy and Planning Group DCT Dental Core Training DDC Domiciliary Dental Care G GDS - General Dental Services GA General Anaesthetic GDP General Dental Practitioner H HDS Hospital Dental Services L LA Local Anaesthetic LHB Local Health Board LDC Local Dental Committee LOC Local Orthodontic Committee M MAH Mouth care for Adults in Hospital MCN Managed Clinical Network N NICE National Institute for Health and Care Excellence P PDS Personal Dental Services PHW Public Health Wales R RD restorative dentistry S SCD Special Care Dentistry W WG Welsh Government 6 Abertawe Bro Morgannwg University Health Board

7 Action 1 Develop a Local Oral Health Plan to address the oral health needs of their residents, and clearly describe how they will ensure good governance in commissioning and delivery of all dental services. Key Issues for ABMU Health Board By 2020 to reduce the levels and burden of decay at age 5 among the most deprived quintile of the population to that recorded for the middle deprived quintile By 2020 to reduce the levels and burden of decay at age 12 among the most deprived quintile of the population to that recorded for the middle deprived quintile To continue to support the Designed to Smile Programme To ensure that any new contracted dental activity is in line with the need of the resident population To continue to support and develop on effective clinical governance arrangements Ensure that recall attendances are in line with national guidance and meet the clinical needs of individual patients Increase access to patients needing urgent dental care during normal working hours and remodelling the dental out of hours service to ensure that it is delivering accessible and effective patient care. To ensure that members of the public are supported to take responsibility for ensuring their own good oral health Where we are The current primary care dental contracting arrangements were introduced in Wales in April 2006, with a greater emphasis on locally commissioned dental care. A consequence of this is that Local Health Boards have greater flexibility in planning and providing dental services in line with addressing dental health needs. ABMU Health Board is committed to commissioning any new dental activity in line with the needs of the resident population; however this is moderated by the inflexibilities within the ring-fenced budget. Work is also ongoing through the Dental Strategy Planning Group (DSPG) to ensure that there is alignment between primary, community and secondary care dental services to ensure that patients have access to timely services in the most appropriate clinical setting. A strong focus has already been placed on the governance mechanisms used to ensure that safe and effective services are delivered across the Health Board. These will continue to be reviewed to ensure that they remain appropriate and take into account any changes in national/local policy. ABMU Health Board provides dental services through the following: General Dental Services (GDS) contracts for urgent and routine dental services Personal Dental Services (PDS) agreements for specialist dental services e.g. orthodontics, intermediate oral surgery Community Dental Services for vulnerable groups within the community setting Oral and Maxillo Facial surgery through consultant led services Orthodontics through consultant led services Restorative dentistry through consultant led services 7 Abertawe Bro Morgannwg University Health Board

8 ABMU Health Board delivers a number of consultant led secondary care services to Hywel Dda Health Board and as a result has established a number of working groups and managed clinical networks to ensure engagement from management and professionals across both Health Boards. The reporting mechanisms for the various groups are detailed in the table below: The Dental Strategy and Planning Group is chaired by the Director of Planning for the Health Board who has the executive responsibility for dental services. Membership of the group includes the clinical leads of each of the working groups/mcns, as well as colleagues from across the Health Board who deliver dental services, Public Health Wales, the LDC and Hywel Dda Health Board. In addition to the conventional access streams to NHS dental services ABMU Health Board also facilitates innovative access through the Dental Training Unit (DTU), based in the Port Talbot Resource Centre. Patients attending the DTU are, in the main, treated by Dental Core Training Post Year 1 dentists (DCT1), who are recruited on an annual basis. The DTU also has two senior supervising dentists, a trainee therapist and a team of qualified and trainee dental nurses. A High Need referral scheme has been established which enables local dental practices to refer high need patients e.g. those patients who need a significant amount of dentistry to enable them to become dentally fit, to the DTU for a course of treatment, thereby releasing capacity for general dental practitioners. When treatment is completed, the patient is referred back to the general practice for any future care. This scheme has already improved local access to NHS dentistry across the Health Board and been offered to all practices in the Neath Port Talbot area and has been extended to some to practices in Swansea and Bridgend. When capacity increases, the scheme will be offered more widely across ABMU. The DTU was expanded in early 2013 to include three surgeries and a laboratory facility for the provision of restorative dentistry that was previously undertaken at Princess of Wales Hospital and Neath Port Talbot Hospitals. A proposed service model to integrate dental services operating at the Port Talbot Resource Centre is currently being explored. The model includes the integration of the DTU, Community Dental Service, Restorative Dentistry and elements of Minor Oral Surgery working in collaboration where possible and a single point referral system to manage dental activity. Furthermore, the development of a two-year longitudinal DCT Training Scheme, building on the success of the current DFT scheme and 8 Abertawe Bro Morgannwg University Health Board

9 also ensure that numbers of trainees are consistent year on year. This development would provide the opportunity for broader postgraduate training experience and produce dentists with experience in several dental specialties. ABMU Health Board is also fortunate to have two dental practices in Swansea who are participating in the Welsh Government Dental Contract Quality and Outcome Pilots established to look at new ways of providing care for patients that link to access, quality of services and disease prevention in adults and children. The Health Board has also recently awarded contracts for the provision of intermediate oral surgery services (patients requiring more complex dental extractions under local anaesthetic) from two community based practices in Swansea. Both practices accept referrals from all dental practices across ABMU. It is anticipated that this new service model will see a reduction in the number of patients referred into secondary care for procedures that can be safely undertaken in a primary/community setting. Deprivation, Primary Care Dental Servicer Use and Provision in Relation to Need 2012/13 The Welsh Index of Multiple Deprivation (WIMD) 2011 is the official measure of relative deprivation for small areas in Wales. It was produced by the Welsh Government as a tool to identify and understand deprivation in Wales. Deprivation is a wider concept than poverty. Poverty is usually considered to be a lack of money, whereas deprivation includes a lack of opportunities and resources to which we might expect to have access in our society, for example good health, protection from crime, a clean and safe environment. Multiple deprivation therefore refers to the different types of deprivation that might occur. Eight types of deprivation, or domains, are included in the Index. These are: employment, income, education, health, community safety, geographical access to services, housing and physical area. Ranks are a relative system of measurement; we can know which areas are more (or less) deprived than others, but not by how much. WIMD is produced at lower layer super output areas (LSOAs), the geographical size of these small areas varies quite widely, and depends on the local population density, the populations are intended to be the same in each LSOA, with an average population of 1,500 people. LSOAs were designed by the Office of National Statistics to have consistent population sizes and stable geographies, so that statistical comparisons of small areas over time can be carried out. Within each Local Health Board the distribution of deprivation varies. In this report the deprivation score for individual LSOAs are ranked on an All Wales basis. Table 1 below shows the size and proportion of the LHBs population that falls within each WIMD 2011 quartile. Chart 1 shows the proportion by percentile. 9 Abertawe Bro Morgannwg University Health Board

10 Table 1: Population within WIMD 2011 Quartiles Quartiles Rank LHB Population % of LHB Population % of Wales Population 25% Most deprived 149, % Most deprived 133, % Least deprived 82, % Least deprived 137, Total 502, Chart 1: Population within WIMD 2011 Percentiles This information shows that the LHBs population is over-represented in the most deprived areas and to a lesser extent the least deprived areas. The LHBs population is considerably under-represented within the median deprived communities compared with Wales as a whole, particularly those area in the 60 to 80% least deprived areas. Map 1 (below) shows the WIMD 2011 score relative to the LHB area only, i.e. ranking only LSOAs in the LHB. Those areas shaded yellow are the most deprived relative to the LHB area. Main towns or cities are shown for geographical reference. 10 Abertawe Bro Morgannwg University Health Board

11 Map 2 (below) shows LSOAs in the area which fall into national WIMD 2011 quartiles i.e. the 25% most deprived to 25% least deprived nationally. Main towns and cities are shown for geographical reference. Based on the needs analysis ABMU Health Board undertook a tender exercise in 2012/13 to commission additional dental activity in the areas of highest need, with new contracts being awarded in Sketty/Uplands (Swansea), Pontardawe (Neath Port Talbot) and Maesteg 11 Abertawe Bro Morgannwg University Health Board

12 (Bridgend). The average distance travelled by patients from their home to a dentist was 5km. 64% of the ABMU resident population attended a NHS dentist at least once in the 24 month period between April 2011 and March 2013, compared to 58% across Wales; with a greater proportion of females (67%) attending compared to males (61%). Attendance rates were highest in children with 88% of 6 to 17 year olds attending the dentist at least once during the same period. However, attendance rates are closely related to levels of deprivation with children resident in the least deprived areas consistently attending a NHS dentist compared to those in most deprived areas. This pattern is however reversed in adults with higher rates attending a NHS dentist in the most deprived areas. The National Institute for Health and Clinical Excellence (NICE) published guidance in October 2004 sets out to help dentists assign recall intervals between oral health reviews that are appropriate to the needs of individual patients which can range between 6 and 24 months. From the 2012/13 data the most common re-attendance interval for adult patients is 6 to 8 months, which suggests that a significant number of patients and their dentists are continuing with the long established pattern of twice yearly attendance whilst the recall interval for patients living in the most deprived areas was shorter (e.g. 3 months). Children s Oral Health Dental health targets were set for Wales in Eradicating Child Poverty in Wales Measuring Success (2006): In summary: By 2020 to reduce the levels and burden of decay at age 5 among the most deprived quintile of the population to that recorded for the middle deprived quintile By 2020 to reduce the levels and burden of decay at age 12 among the most deprived quintile of the population to that recorded for the middle deprived quintile Whilst there are no specific Local Health Board targets, we can use the Welsh targets as a benchmark. There has been an improvement in both the average DMFT and the %DMFT>0 for children living in the ABMU area between 2007/08 and 2011/12. ABMU Health Board will continue to address this inequality in experience of child tooth decay over the next five years. For the most deprived fifth of 5 year old children in Wales, the average DMFT (decayed, missing due to caries and filled index) was 2.65 in 2007/08 when the baseline was set. The national child poverty target is to bring this average down to 1.77 by In 2011/12 the average dmft for the most deprived group was 2.16; half a tooth reduction when compared with 2007/08 and good progress towards the 2020 target. The results of the Wales 2011/12 survey of 5 year olds suggest that prevalence of dental caries is improving but this needs to be confirmed by reviewing the results of future surveys, the next being scheduled for 2015/16. It is important to note that these are Welsh targets as to date there are no Health Board targets. The sum of decayed, missing and filled teeth is a measure of the decay experience of the average child. It is the burden of disease which theoretically could have been prevented. Average dmft scores for Welsh Local Health Boards in 2007/08 and 2011/12 are presented in the table below. ABMU Health Board experienced a statistically significant reduction, with the averages being 2.1 and 6.1, with the mean being similar to the Welsh average for both. 12 Abertawe Bro Morgannwg University Health Board

13 dmft Average dmft for 5 year olds, Welsh Local Health Boards 2007/08 compared with 2011/ WALES ABMU Aneurin Bevan Betsi Cadwaladr Cardiff & Vale Cwm Taf Hywel Dda Powys The table below illustrates the proportion of children with at least one decayed tooth (%dmft>0) by LHB in 2007/08 and 2011/12. Although there appears to be a general tendency (except in Cwm Taf) for a reduction in the proportion of children with decay experience, the changes only reach statistical significance in Aneurin Bevan and Hywel Dda LHB areas. Percentage of 5 year olds with caries experience (%dmft>0), Welsh Local Health Boards, 2007/08 compared with 20011/12 The %dmft>0 for ABMU Health Board in 2011/12 was 44.2% which was within the average range when compared with the Welsh average of 41.4% The average number of children with decayed teeth among the children with at least one decayed tooth is shown in the table below. There is a general tendency for a reduction in the mean scores; the only change shown which reaches statistical significance is in ABMU where the averages for 2007/08 and 2011/12 were 4.4 and 3.7 respectively. 13 Abertawe Bro Morgannwg University Health Board

14 dmft dmft of those with dmft Average dmft of those with caries experience for 5 year olds, Welsh Local Health Boards 2007/08 compared with 2011/ WALES ABMU Aneurin Bevan Betsi Cadwaladr Cardiff & Vale Cwm Taf Hywel Dda Powys The decayed teeth component of preventable decay (dmft) measures active decay. This puts the child at risk of pain, infection and suggests risk of decay of permanent successor teeth. In the past it has been called untreated diseased. The concept of treating all decay in teeth which will be shed later by providing fillings/extractions is being questioned. Many of these children need measures to empower control sugar in the diet, improve access of teeth to fluoride and ensure removal of dental plaque, as opposed to operative dental procedures. This decayed teeth data is now regarded as a marker for children who need support in managing this chronic dental disease. Between 2007/08 and 2011/12 there was a statistically significant reduction in averaged dmft for Wales with the values being 2.0 and 1.6 respectively. During 2007/08 the average dmft values for all three ABMU unitary authorities (UA) were within the average range when compared with Wales for the same year WALES Bridgend Neath Port Talbot Swansea For Bridgend UA there was a notable reduction in average dmft between 2007/08 and 2011/12, from 1.7 to 1.1, but this difference was not statistically significant. However, the 14 Abertawe Bro Morgannwg University Health Board

15 %dmft>0 average dmft for the UA in 2011/12 was statistically lower that the Welsh average for the same year. Between survey years the average dmft for Neath Port Talbot showed little change (2007/08: 2.1 compared to 2011/12 2.2). The dmft for the UA in 2011/12 of 2.2 was statistically higher than the Welsh average for the same year. Swansea UA experienced a significant reduction in average dmft between 2007/08 (2.2) and 2011/12 (1.6). The dmft for both surveys was within the average range when comapred with the Welsh value for the same survey. The %dmft>0 for Bridgend fell by almost 10% between 2007/08 and 2011/12, from 45.2% to 35.5%; because of the wide confidence intervals linked to smaller sample sizes, this change was not statistically significant. The %dmft>0 for Bridgend for both surveys fell within the average for Wales (table below) Percentage of 5 year olds with caries experience (%dmft>0) in unitary authorities within ABMU Health Board 2007/08 compared with 2011/ WALES Bridgend Neath Port Talbot Swansea The %dmft>0 for Neath Port Talbot showed little change over the two surveys 2007/08 (49.1%) and 2011/12 (52.6%). The %dmft>0 for the UA in 2011/12 was 52.6% statistically higher than the Welsh percentage for the same year. The %dmft>0 for Swansea showed little change little change over the two surveys 2007/08 (48.8%) and 2011/12 (44.2%); also it fell within the average range for Wales at both time points. Looking at those children who have at least one decayed, missing or filled tooth illustrates the stark differences between children with decay and those without. The average dmft for a child with dmft is shown in the table below. 15 Abertawe Bro Morgannwg University Health Board

16 dmft of those with dmft WALES Bridgend Neath Port Talbot Swansea For Wales overall, the reduction from 4.2 in 2007/08 to 3.8 in 2011/12 does suggest an improving position. In Bridgend there was a reduction in average dmft of those with dmft between the two surveys from 3.7 to 3.2 but this difference was not statistically significant. However the average dmft for the UA in 2011/12 was statistically lower that the Welsh average for the same year. Between survey years the average dmft for those with dmft in Neath Port Talbot showed little change 2007/08 (4.4) to 2011/12 (4.3). This variable fell within the average range for Wales for both surveys. The average decayed tooth (dt) of children who have at least one decayed, missing or filled tooth for Wales fell between 2007/08 and 2011/12 from 2.9 to 2.6. This statistically significant improvement represented a reduction of almost 1/3 rd of a tooth. The dt experience of those with decay in Bridgend was lower than that of all Welsh 5 year olds for both surveys 2.2 in 2007/08 and 1.9 in 2011/12, this however is not considered to be statistically significant. In Neath Port Talbot the average dt of those with decay almost plateaued between the two surveys, 3.1 and 3.1 in 2007/08 and 2011/12 respectively. Similarly the average dt in Swansea showed little change between the two survey dates 3.0 in 2007/08 and 2.8 in 2011/12; on both occasions these fell within the average rates for Wales. The overall picture is one of improvement in the unitary authority breakdown of the data for Bridgend and to a lesser extent in Swansea; however this is not evident in the data for Neath Port Talbot. Efforts need to be focussed on Neath Port Talbot to ensure that inequalities do not widen. The consequences of poor child oral health are multiple and all the more concerning because they affect the youngest members of our society. Tooth decay commonly results in pain and infection, often resulting in sleepless nights, time off school and possibly the need for effective treatment under General Anaesthesia. On average across Wales in a class of thirty five year olds, four children would have experienced dental pain in the last 12 months. The Welsh Government launched the Expansion of Designed to Smile A National Oral Health Improvement Programme in 2009, which is Wales national child oral health programme. The programme sets out to improve the oral health in children by a targeted, 16 Abertawe Bro Morgannwg University Health Board

17 preventative approach in the areas of greatest need. The local D2S programme is described under Action 3 on page 19. ABMU Governance Arrangements for GDS/PDS Contract Management The Associate Medical Director (AMD) for Dentistry holds the responsibility for ensuring that robust governance arrangements are in place for primary care dental services, this is underpinned through a number of key mechanisms: Clinical Governance Committee for Dentistry Chaired by the AMD for Dental, this group meets on a quarterly basis and reviews governance issues with representation from Localities, Community Dental Service, Chairs of dental managed clinical networks, Public Health Wales and the Deanery. The remit of this group is to oversee clinical governance in dental services contracted to or directly provided by the Health Board. Public Health Wales Quality Assurance System (QAS) All contracted dental services through General Dental Services (GDS) contracts or Personal Dental Services (PDS) agreements have a requirement under Part 10, Paragraph 79 of the Regulations to: The contractor shall comply with such clinical governance arrangements as the Primary Care Trust may establish in respect of contractors providing services under a contract. The contractor shall nominate a person who manages services under the contract to have responsibility for ensuring compliance with clinical governance arrangements. In this paragraph, clinical governance arrangements means arrangements through which the contractor endeavors to continuously improve the quality of its services and safeguard high standards of care by creating an environment in which clinical excellence can flourish. All general dental contractors in ABMU participate in the annual on line QAS self assessment process managed by Public Health Wales on behalf of the Health Board, which satisfies this section of the Regulations. The self assessment tool covers a number of domains including compliance with HTM01-05 (decontamination), IRMER regulations, child protection training etc. Exception Reporting The Health Board has an agreed policy with the Local Dental Committee on the management of contract performance information on a quarterly basis which identifies any exceptions within a contract. These are normally exceptions that are known to the locality teams e.g. a contract that has a high level of urgent treatments recorded could provide a number of access sessions for patients who do not have a regular dentist and present with urgent dental needs. There has however through the management of this process been recognition that in larger dental practices it is more difficult to identify where there are issues of exception that need investigation. An addendum to the policy has been developed for localities to review multiple claims per patient from the electronically transferred data from dental practices to the Dental Practice Division on a quarterly basis. Where there appears to be a high level of attendance rates for patients; practices will be asked to review these in line with the exception reporting policy. 17 Abertawe Bro Morgannwg University Health Board

18 Contract Monitoring Process Where dental contracts are achieving less than 30% of their contracted activity at the midyear point, practices are engaged in discussions over their ability to achieve their contracted level of activity for that year. Where necessary, contract adjustments are made on a temporary or permanent basis. Once the Health Board has received the end of year data however, all practices are subject to a visiting programme where a standard agenda is discussed and the details of the visit are documented. This is managed on a consistent basis across all three localities, and will include ensuring that any outstanding from the QAS process have been completed, actions from any Dental Reference Officer visits have been undertaken, updates on changes in legislation etc. Dental Performance Scorecard Recently introduced, the localities are using a scorecard mechanism to review all known data about their dental practices to flag where there are potential areas for concern using a number of key indicators. High level discussions about these practices are conducted with a small group that includes locality representatives, Dental Practice Advisors from PHW and the Associate Medical Director for Dentistry prior to the Clinical Governance Committee for Dentistry to ensure that the correct actions are undertaken in relation to the concerns that are being raised. Primary Care Performance Procedures A high level performance team has been established pan-abmu to consider performance issues and is being led by the Associate Medical Director for Dentistry. Underpinning the primary care performance process are The National Health Services (Performers List Regulations) Wales (2004) under which Part 2, Regulation 10 sets out the reasons why a Health Board may chose to remove a performer from the Performers List. As with all other primary care contractors, NHS dental contractors are also subject to the All Wales Primary Care Performance Procedures, where concerns over an individual s performance is managed through a national framework. The Welsh Government Updated Guidance on a Model Operating Procedure for the Management of Dentists on the Dental Performers List whose Performance is of Concern (October 2012) sets out the revised process for managing concerns to ensure that the safety and wellbeing of patients is protected; that a response is given to expressions of concern about practitioner performance at the earliest stage; a structured framework for the review and/or investigation of concerns; to ensure any review or investigation is open, transparent and fair to all parties; provides an accurate assessment and report upon which to base decisions and appropriate action and focuses on good practice and improved performance. Management of NHS dental complaints All dental practices are required under the Regulations Part 7 Paragraphs 47 to 52 set out the process dental practices need to have in place to manage complaints and investigations in a timely manner. The NHS Business Services Authority Clinical Advisors are qualified dentists who are able to undertake impartial case reviews of complainants where there is a dispute over the clinical treatment provided. 18 Abertawe Bro Morgannwg University Health Board

19 The Dental Reference Service In addition to offering patient examinations the NHS Business Services Authority currently provide Health Boards with support in a number of areas: Dental Practice Inspections Clinical Record Reviews Patient questionnaires The service also undertakes a rolling visiting programme of dental practices whereby a random sample of clinical records are reviewed and reports highlighting any areas of concern are sent to the Health Board which are then addressed through the annual contract monitoring visiting programme as well as being fed into the dental performance scorecard. Where we need to be Consideration and approval has been given from the DSPG for the development of a single point of access for all dental referrals received into the Health Board. To support this work a task and finish group has been established to look at the development of robust referral guidelines and referral templates to assist in better referral management. The DSPG has also agreed a proposal to appoint a dedicated project manager to take forward the development and integration of dental services provided out of the Dental Training Unit. There is recognition also that the Health Board needs to have improved access for urgent dental care during the working day, which will be managed in parallel with a review of the dental out of hours service, to ensure that patients have timely access to appropriate services. In addition, Her Majesty s Prison in Swansea has a waiting list for dental appointments which has resulted in 26 complaints between April 2012 and March 2013, additional investment was put into the prison dental service in 2012/13 following the recalculation of the Patient Charge Revenue by Welsh Government and the directive that Health Boards use this funding to support access issues. However this is not recurrent funding and there is the potential for the waiting list to continue to grow. Further work needs to be undertaken with the Operative Dentistry and Oral Surgery Working Groups to refine them into Managed Clinical Networks. Areas of good practice Development of multi-faceted approach to governance for contract management DTU pilot scheme, supporting patients with high need for dental treatment to enable them to become dentally fit A review of the child GA service provision to ensure that it remains fit for purpose and meets national guidance Development of the MCN for Orthodontics working across ABMU and Hywel Dda Health Boards Requests to Public Health Wales to undertake independent reviews of dental services 19 Abertawe Bro Morgannwg University Health Board

20 Risks A lesser reduction in the DMFT rates than anticipated to meet the 2020 target Availability of appropriate financial resources to deliver revised models of care Isolated management teams not facilitating integrated planning and delivery of dental services Current contractual arrangements do not easily enable a preventative oral health promotion approach Difficulty in accessing public transport to ensure that children are accessing regular dental care Implementation of a new contract during the Oral Health Plan period could impact on the ability of the Health Board to deliver against some of the identified actions Summary of Health Board Actions: Continue to support the D2S programme and remain committed to child dental health improvement and a reduction in child dental general anaesthetics Work with Swansea Poverty Forum to review data on children s oral health to fit with the Target Area work that is being undertaken Ensure that the management structure for dental services across ABMU remains fit for purpose and ensures that resources are targeted appropriately to meet patient need Management and deployment of appropriate resources to ensure that effective service changes are enacted Support the further development of the DTU pilot to enable more patients to have access to the service Take forward the integration of dental services and development of care pathways across the Health Board Take forward the integration of dental services and dental training model provided at Port Talbot Resource Centre Develop a central referral management system for all dental referrals ensuring that referral pathways and templates are robust and fit for purpose 20 Abertawe Bro Morgannwg University Health Board

21 Action 2 Health Boards will be expected to work with dentists and their teams, and all other relevant stakeholders to develop and support delivery of Local Oral Health Plans Key Issues for ABMU Health Board Ensuring contributions are sought from service and clinical leads across ABMU, including Public Health Wales Ensuring effective engagement with a wide variety of stakeholders on the development of the ABMU Oral Health Plan, including o All members of the Community Dental Service o The Local Dental Committee o LHB/LDC Liaison Group o Local Authorities o Designed to Smile steering group o Study day for all NHS dentists and their teams o Hospital dental teams o The management teams of Swansea, Neath Port Talbot and Bridgend localities o Cancer Network o Hywel Dda Health Board o Cardiff and Vale Health Board o Dental Strategy and Planning Group Developing a five year plan that sets clear objectives and milestones that can be signed up to by the Board Where we are A programme of engagement has been developed to support the full development and ownership of the ABMU Oral Health Plan. The LDC, Hospital dental teams, Public Health Wales and the Community Dental Service have been included in the drafting of the initial plan to ensure that there is ownership for the actions identified to facilitate successful implementation of a five year plan that will set out the strategic direction for the delivery of dental services in ABMU. Where we need to be During September we need to be undertaking an engagement exercise both internal within the Health Board but with external partners and agencies, before finalising the draft document during October ABMU Health Board will be presented with the final plan in November 2013 with it being ready for submission to Welsh Government by the December 2013 deadline. Areas of good practice 21 Abertawe Bro Morgannwg University Health Board

22 We already have a number of existing forums where we can take the document for discussion, and have planned a number of other meetings and events to ensure that all members of the dental profession are engaged in the process. Risks We were working within a tight timescale leading off the summer holiday period which meant that some individuals were late in joining the development process Summary of Health Board Actions: A set programme of engagement to ensure wide ranging views are sought on the draft document Finalisation of the draft plan during October 2013 to enable Board sign off in November 2013 Submission to Welsh Government by 31 December Abertawe Bro Morgannwg University Health Board

23 Action 3 Ensure the continued participation in evidence based community oral health promotion programmes particularly the Designed to Smile and Healthy Schools programmes. Key Issues for ABMU Health Board Remain committed to the Designed to Smile (D2S) programme Support the D2S Steering Group and ensure the Designed to Smile Programme remains effective and cost efficient. Build stronger links and partnership working between health and other agencies, and strengthen working with education and GDP s. Where we are Scientific evidence suggests almost every proven method to prevent decay includes delivery of fluoride to teeth surfaces. We recognise that water fluoridation would have the greatest benefit to dental health, however due to legal, political and financial implications associated with fluoridating water supplies in Wales the message the Welsh Government has continued to convey in relation to fluoridation is important to note: The Welsh Government has no current plans to fluoridate water supplies in Wales. The Welsh Government acknowledges that in view of the poor dental health in Wales, the introduction of water fluoridation has the potential to deliver significant health gains and address health inequalities. In the absence of water fluoridation, ABMU Health Board continued to support the national and local D2S programmes as a means of improving the oral health of children in the area. An established and multidisciplinary D2S steering group with representatives from: Community Dental Service, Local Dental Committee, ABMU HB Health Visiting Finance, Public Health Wales, A Dental Practice Manager, Healthy Schools and Pre-school Schemes from the three local Authorities. Designed to Smile has robust reporting processes; through the annual submission of monitoring data to the Welsh Oral Health Information Unit (WOHIU) and to ABMU Health Board via the Dental Services Strategy and Planning Group. Evaluation of the programme at local and national level is conducted by the Dental Public Health Department at Cardiff Dental School, and the BASCD national annual child dental health surveys funded by the Welsh Government. Data from the 2011/12 child dental survey showed an overall improvement (6%) in the dental health of 5 year olds in Wales, although it is too early to confirm if this is predominantly down to D2S. The survey has also indicated a 17% improvement in children attending schools participating in D2S but this data has to be treated with caution, the next surveys will hopefully confirm an improving trend. 23 Abertawe Bro Morgannwg University Health Board

24 The local D2S team has forged strong working relationships with the Healthy School and Pre School Schemes within the Health Board. Healthy and Pre-school co-ordinators help recruit schools/settings to the programme and also provide D2S with additional support should issues arise, e.g. schools selling inappropriate snacks, or consider withdrawal from the programme. The local D2S programme provides financial support to the Healthy School and Pre-school schemes to cover supply costs to enable staff to attend training sessions around oral health and well being. The fissure sealant programme has been established using the new mobile dental unit and the fluoride varnish programme is underway following completion of staff training. In April 2012 the management of the Community Dental Service and the Designed to Smile programme in Bridgend transferred to Abertawe Bro Morganwwg University Health Board from Cardiff and Vale Health Board. Following this transfer, and the disparity in programme delivery identified, the focus has been to work towards an equitable D2S programme across the Health Board. This entailed the recruitment of additional staff and the procurement and refurbishment of suitable office and storage spaces in the Bridgend area. Oral health education training and awareness raising of the Designed to Smile programme is offered to a range of professionals and local agencies such as School Health Nurses, Health Visitors, Dieticians, GDPs, Community Drugs and Alcohol Team and the Voluntary Sector. Where we need to be We must ensure the D2S be maintained as the key component of our strategic approach to oral health improvement. We will ensure it is embedded in to the fabric of schools, settings and professional practice. The Steering Group will engage with head teachers to improve knowledge of the programme and address issues such as non compliance with daily brushing and the opting out of schools. The Welsh Government has recently published A Quality Standards Framework for the Designed to Smile Programme in Wales. The framework has been designed to benchmark individual Designed to Smile Schemes and ensure that the service remains both effective and cost efficient. In response the D2S Steering Group is required to produce an annual report to the Chief Dental officer detailing compliance with the standards. To do so requires delivery of the core programme which includes the supervised tooth brushing programme for the 3-5 age group; the fissure sealant programme where clinically appropriate and the fluoride varnish program for 3-5 year olds. This academic year the fluoride varnish programme will be implemented by D2S team members using domiciliary kits in schools. The links between D2S and GDS needs to be improved. We need to work with Public Health Wales to use the child dental health survey and child general anaesthetic data to better target D2S resources. In addition we need to work with LDC to develop a policy for ensuring that children who have a dental GA, and thus by default are high risk, have extended preventative care. There are potential opportunities for D2S to extend its brief into health promotion initiatives like smoking cessation, but this is to a degree dependant on additional resources or Welsh Government redirecting part of the existing programme. 24 Abertawe Bro Morgannwg University Health Board

25 Areas of good practice The development of a multiagency steering group identified within the Quality Standards Framework for the Designed to Smile Programme. The establishment of strong partnership working with the local Healthy Schools and Pre- School Schemes and a range of other stakeholders. Risks Schools opting to withdraw from programme. Assumption that there will be no changes to D2S funding following the outcome of the Health Improvement Review conducted earlier this year. Commitment to funding beyond 2014/15. Summary of Health Board Actions: To comply with the Quality Standards Framework for the Designed to Smile Programme To deliver the Designed to Smile Programme in accordance with WG requirements including fissure sealant and fluoride varnish application programmes Submit robust annual monitoring data to the Welsh Oral Health Information Unit Establish links and develop working relationships with GDP s To review child dental health survey and child dental GA data to inform the delivery of the local D2S programme We need to work with the LDC to develop a policy for ensuring that children who have had a dental GA and thus by default are high risk, have extended preventative care 25 Abertawe Bro Morgannwg University Health Board

26 Action 4 Liaise with the Cancer Networks and the Head and Neck Cancer National Specialist Advisory Group to ensure that the Welsh Cancer Standards (2005) are implemented. Health Boards to work together to ensure evidence based multi-disciplinary care is available to all of their patients diagnosed with oral cancer. We will seek assurance that any identified variation in treatment outcomes is addressed by the Cancer Networks. Key Issues for ABMU Health Board Where we are The Data for Head and Neck Oncology (DAHNO) produced an Information Pack for Head and Neck Cancer MDTs in Wales in August 2012, which set out the data collection requirements for the annual audit (November 2012), and captured activity relating to patients diagnosed between 1 November 2011 and 31 October Whilst recognising that it is one of the Welsh Governments longer term outcomes to have a reduction in the percentage of oral cancer patients presenting at stage 3 or 4 and an increase in the percentage of patients presenting with stage 1 or 2, due to the demographics of the ABMU and Hywel Dda Health Board areas the trend is forecast to continue to increase over the next decade. The incidence of oral cancer is increasing in women which is considered to be directly related to an increase in smoking and the consumption of Alcopops. The presenting age of patients with oral cancer is also decreasing. The Welsh Cancer Intelligence Surveillance Unit (WCISU) Triennial report 2011 (table below) demonstrated the incidence of head and neck cancer survival rates after one and five years. Local Health Board Betsi Cadwaladr University Powys Teaching Hywel Dda Abertawe Bro Morgannwg University Cwm Taf Aneurin Bevan Cardiff & Vale University One year Five year (67.3,76.4) (76.4,83.9) (76.2,83.2) (44.8,55.7) (52.2,62.0) (63.0,84.6) (56.0,78.4) (62.7,83.1) (37.6,64.1) (39.7,65.4) (69.7,80.8) (69.8,80.9) (67.9,78.4) (44.2,57.9) (45.4,58.9) (77.7,85.9) (66.8,76.8) (74.0,82.4) (53.6,64.9) (49.0,60.6) (67.3,80.0) (63.7,77.2) (63.3,75.5) (43.6,58.9) (38.9,54.3) (65.0,75.6) (72.8,82.5) (70.2,79.2) (40.3,52.7) (46.9,59.6) (66.4,78.1) (70.3,81.2) (74.5,84.1) (41.9,55.5) (47.3,61.0) The report also identified the incidence of oral cancer by Local Authority area set out in table 2 below. 26 Abertawe Bro Morgannwg University Health Board

27 Local Authority Total cases Wales ASR (95% CI) EASR (95% CI) Total cases Wales ASR (95% CI) EASR (95% CI) Total cases Wales ASR (95% CI) EASR (95% CI) Isle of Anglesey (8.7, 16.5) 9.2 (6.6, 13.2) (14.3, 23.6) 14.5 (11.2, 19.2) (15.2, 24.7) 16.1 (12.6, 21.1) Gwynedd (11.9, 18.3) 12.0 (9.6, 15.2) (14.1, 21.1) 14.8 (12.0, 18.3) (15.6, 22.7) 14.6 (12.0, 18.0) Conwy (13.6, 20.4) 13.5 (11.0, 17.0) (14.0, 20.9) 14.1 (11.5, 17.6) (14.9, 21.9) 13.6 (11.1, 17.0) Denbighshire (15.4, 23.5) 16.0 (12.8, 20.2) (11.7, 18.9) 12.0 (9.4, 15.7) (15.9, 24.0) 15.6 (12.7, 19.6) Flintshire (10.9, 16.8) 11.1 (8.9, 13.9) (12.4, 18.4) 12.1 (9.9, 14.9) (16.2, 22.8) 15.4 (12.9, 18.4) Wrexham (11.8, 18.2) 12.2 (9.8, 15.4) (12.5, 19.0) 13.0 (10.5, 16.2) (13.9, 20.6) 13.2 (10.8, 16.3) Powys (10.1, 15.8) 10.3 (8.2, 13.2) (9.6, 15.1) 9.6 (7.7, 12.4) (9.5, 14.8) 8.5 (6.8, 11.0) Ceredigion (15.6, 25.1) 16.3 (12.8, 21.3) (11.8, 20.0) 12.6 (9.7, 17.1) (12.1, 20.3) 11.7 (8.9, 16.1) Pembrokeshire (13.5, 20.5) 13.8 (11.2, 17.4) (12.6, 19.1) 12.7 (10.2, 16.0) (13.5, 20.1) 13.2 (10.8, 16.5) Carmarthenshire (12.8, 18.0) 12.9 (10.8, 15.6) (12.4, 17.5) 11.8 (9.9, 14.3) (14.3, 19.7) 13.2 (11.2, 15.7) Swansea (19.4, 24.9) 18.1 (15.9, 20.7) (13.6, 18.4) 12.8 (11.0, 15.1) (15.8, 21.0) 15.0 (13.0, 17.5) Neath Port Talbot (18.3, 25.4) 18.3 (15.4, 21.8) (12.5, 18.6) 12.5 (10.2, 15.5) (15.0, 21.6) 14.8 (12.3, 17.9) Bridgend (13.2, 19.8) 13.7 (11.1, 16.9) (13.8, 20.5) 14.0 (11.4, 17.3) (14.6, 21.3) 14.5 (12.0, 17.8) Vale of Glamorgan (12.0, 18.7) 12.9 (10.3, 16.3) (12.9, 19.7) 12.9 (10.4, 16.2) (13.1, 19.8) 12.4 (10.0, 15.5) Rhondda Cynon Taff (14.5, 19.5) 14.3 (12.3, 16.7) (15.2, 20.3) 14.1 (12.1, 16.4) (17.2, 22.6) 15.5 (13.5, 17.9) Merthyr Tydfil (13.9, 25.0) 16.0 (11.9, 21.9) (9.8, 19.6) 11.1 (7.8, 16.1) (17.5, 30.0) 17.8 (13.6, 23.7) Caerphilly (13.8, 19.8) 13.6 (11.3, 16.4) (11.0, 16.4) 10.8 (8.8, 13.3) (14.5, 20.5) 13.6 (11.4, 16.3) Blaenau Gwent (11.6, 20.4) 13.6 (10.2, 18.3) (12.5, 21.6) 14.0 (10.6, 18.8) (11.2, 20.0) 11.6 (8.7, 16.1) Torfaen (9.5, 16.7) 10.5 (7.9, 14.1) (11.8, 19.5) 12.5 (9.7, 16.3) (11.4, 18.9) 11.4 (8.8, 15.0) Monmouthshire (7.9, 14.6) 8.4 (6.2, 11.9) (7.0, 13.5) 7.4 (5.3, 10.8) (10.8, 18.2) 10.7 (8.2, 14.5) Newport (11.9, 18.2) 12.3 (9.9, 15.4) (10.3, 16.1) 10.5 (8.4, 13.4) (17.0, 24.2) 16.3 (13.6, 19.7) Cardiff (14.5, 19.1) 14.4 (12.5, 16.7) (14.3, 18.9) 13.6 (11.8, 15.7) (18.7, 24.0) 16.7 (14.7, 19.0) WALES (15.6, 16.9) 13.6 (13.1, 14.2) (14.7, 15.9) 12.5 (12.0, 13.1) (17.0, 18.4) 14.0 (13.4, 14.6) Where we need to be Whilst there is a forecast increase of the incidence of oral cancer by 17% in the next 5 years; there has already been an increase of 100% in incidence in the past 10 years due to a 50% increase in case incidence in Wales and a centralisation of cases in the Swansea s Multi- Disciplinary Team with the cases being brought in from West Wales. Evidence that screening and follow up after 3 years is negligible. Developing an awareness raising campaign targeted at the public in order to increase the number of patients who identify oral cancer at an early stage that sets out the key risk factors for patients, and the symptoms they should be presenting with. It is important to understand the demographics of this group when considering how publicity campaigns should be used to target the at risk groups of patients. We also need to raise awareness and understanding that the prevalence of HPV is on the increase and the associated risks of oral cancer. Areas of good practice Multi-Disciplinary Team meetings in South West Wales are held on a regular basis and are delivering against most of the Welsh and national standards for head and neck standards. Follow up clinics have been reviewed and as a result have been streamlined and are working more effectively. The Health Board has a planned education for GDPs in December 2013 and the agenda will include a session on the early identification of oral cancer. Risk Increase in number of patients presenting with stage 3 and 4 due to the demography of the area Insufficient resource to deal with the growing demand that has been estimated Low percentage of regular attendees for routine dental care increases the risk for those patients not being screened 27 Abertawe Bro Morgannwg University Health Board

28 Delay in treatment following outpatient assessment is a risk linked to resource issue with beds Lack of access to regular dental care for post operative oral cancer patients for ongoing dental care HPV immunisation may change prevalence of oral cancer in females, immunisation of males may reduce the number of cases of oral cancer (long term control) Summary of Health Board Actions: Review of the communications strategy needed to target the at risk groups of developing oral cancer Planning services, both in the short and longer term to meet the anticipated need for the service, whilst ensuring that waiting times are managed with the RTT guidelines Continue to have regular input into the MDT meetings, to ensure excellence of clinical practice 28 Abertawe Bro Morgannwg University Health Board

29 Action 5 Use the recommendations from the Special Care Dentistry Implementation Plan in ensuring that the needs of all vulnerable groups are addressed Key Issues for ABMU Health Board Oral care should be integrated into the general health and social care plans and/or pathways of patients with special care needs e.g. those with complex medical and social problems Implement the recommendations from the Special Care Dentistry Implementation Plan in ensuring that the needs of all vulnerable groups are addressed Development of regionally agreed referral and care pathways through ABMU and Hywel Dda Health Board Special Care Dentistry Managed Clinical Network (MCN) Where we are ABMU Health Board has recognised the guidance provided by the SCD Implementation Plan. A MCN in Special Care Dentistry (SCD) for ABMU and Hywel Dda Health Boards has been established which meets on a quarterly basis and has membership that includes the clinical leads of ABMU and Hywel Dda Community Dental Services, Specialists in Special Care Dentistry, Hospital representation in Special Care Dentistry, General Dental Service (GDS) representatives from ABMU and Hywel Dda Health Boards, Public Health Wales representation, ABMU Health Board AMD (Dentistry), Welsh Postgraduate Deanery representation, management representation from ABMU and Hywel Dda Health Boards and DCP and Oral Health Promotion representation from both Health Boards. The SCD MCN is developing a work programme that is initially based upon an audit of what SCD type and level of services is currently being provided, where and by whom. Service specifications and referral and acceptance criteria provided by SCD providers are being collected and will be used to inform the development of referral pathways for SCD across ABMU and Hywel Dda Heath Boards. The MCN recognises the important role of the GDS in the provision of SCD in both Health Boards and seeks to work with GDS representatives to not only develop SCD service provision but also to improve professional links between the GDS the other SCD service providers. Other current work programmes include the development of individual care pathways such as the pathway for patients about to undergo Intravenous Bisphosphonate therapy, support for the Mouth Care for Adults in Hospital programme, an integrated Domiciliary Dental Care service in ABMU Health Board and the development of Conscious Sedation as an alternative to general anaesthesia for vulnerable people. Where we need to be The SCD MCN needs to continue its development work and ensure that the recommendations from the Special Care Dentistry Implementation Plan are addressed. This work will include: Establishing service specifications and referral and acceptance criteria for SCD providers in ABMU and Hywel Dda Health Boards 29 Abertawe Bro Morgannwg University Health Board

30 Ensuring that referral pathways and contact details for SCD providers are published and accessible to those seeking care and that care provided meets currently accepted guidelines in SCD Specific pathways for care are developed (e.g. Bisphosphonate Related Osteonecrosis of the Jaws referral pathway and Patients about to undergo Radiotherapy to the Head and Neck referral pathway) including a pathway for bariatric dental patients Support for the Mouthcare in Hospital programme is developed Development of SCD GA facilities and compliance with the Implementation Pathway for Adults with a Learning Disability Conscious sedation services are developed as an alternative to general anaesthesia. This will include the development of transmucosal sedation The development of links with support groups for vulnerable people to enhance SCD service provision (e.g. care for people resident in nursing homes) Helping to improve training in SCD and the development of Dentists with Enhanced Skills, Clinical attachments and training posts in SCD Developing the role of DCP s in SCD Developing an integrated DDC policy in ABMU HB The role of management in ABMU and Hywel Dda Health Boards should not be forgotten as they will have an important part to play in supporting the role of the SCD MCN in developing care for vulnerable people. Areas of good practice The development of a SCD MCN which is working across ABMU and Hywel Dda Health Board with Public Health Wales support and representation from both Local Dental Committees. The group continues to meet on a quarterly basis and has made considerable headway in the development of referral criteria and referral guidelines. Improvements are being made to the ABMU Health Board SCD GA list with a proposed move to better facilities in the Prince of Wales Hospital in Bridgend. A Joint Clinic in SCD exists in ABMU Health Board staffed by members of the Department of Restorative Dentistry and the Community Dental Service. It is planned to further enhance this service by including members of the Hywel Dda Community Dental Service in the near future. Conscious sedation services are being developed in ABMU and Hywel Dda Health Boards and additional Community Dental Service staff members are currently being trained in the use of conscious sedation in a primary care environment. This will not only enhance conscious sedation services but also reduce the need for treatment under GA. Risks There is a need to be applied observed across ABMU and Hywel Dda Health Boards. Ideally one system of data collection on the provision of SCD is required, carried out in a consistent manner by all SCD providers. This is a challenge because ICT is lacking in certain areas. Lack of training of special care dentistry training courses for dentists could have an impact on developing the service model 30 Abertawe Bro Morgannwg University Health Board

31 Summary of Health Board Actions: To continue development of the MCN in SCD for ABMU and Hywel Dda Health Boards To ensure that the MCN includes representation from the GDS, CDS and HDS and works together across service boundaries to develop dental care for vulnerable people To continue the development of regionally agreed referral and care pathways through the ABMU and Hywel Dda Health Board Special Care Dentistry MCN operating with professional guidance 31 Abertawe Bro Morgannwg University Health Board

32 Action 6 Following recommendations by the National Assembly Children and Young People Committee collect annual data on the number of children who receive dental treatment under GA Key Issues for ABMU Health Board Approximately half (48.5%) of five year olds living in the ABMU area have at least one decayed, missing (due to caries) or filled tooth. The percentages range from 45.2% in Bridgend to 49.1% in Neath Port Talbot. Cardiff University & Public Health Wales (March 2012) The national child poverty target for 2020 is to bring down the average dmft from 2.65 in 2007/08 to The average dmft for 5 year olds during this period in ABMU was 2.14, with 12 of the 17 Upper Super Output Areas (USOAs) being higher than 1.77, ranging from 1.81 (Bridgend U003) to 4.54 (Swansea U005). Cardiff University & Public Health Wales (March 2012) While seeking to reduce the number of dental GAs performed we need to ensure that the Health Board has safe and sustainable GA/conscious sedation services available for children aged 3 to 17 years of age. The need to review the referral data on an ongoing basis to assess the ability to further target the D2S programme to schools where there are a high number of children being referred for extraction/restoration. To ensure that the current service model evolves to include a joint assessment with the service provider and a specialist paediatric dentist. To ensure that all children who are treated under GA/conscious sedation have their treatment plans tailored to ensure that repeat GAs are unnecessary. Where we are ABMU Health Board currently commissions a GA/conscious sedation service from Parkway Clinic to provide care for an approximate number of 1,017 cases annually. The current Service Level Agreement is due to end on 30 September 2013 and a tender process to appoint a service provider for the new model of care from the beginning of October The service aims have been set to ensure that ABMU s contracted dental position for children aged 3 to 17 years of age, who require treatment under general anaesthetic is driven by the children s needs, their best long term interests and minimises risks to them as individuals. The Health Board also seeks to ensure that care is consistent to national standards, local guidelines and policies and that recognised best practice is followed. The service must be provided in a safe environment, by individuals who are competent to deliver the needs of the child and assess their best long term interests. The service provided offers urgent care to patients (e.g. those with an acute and significant dental infection and associated symptoms, requiring treatment under GA/Conscious Sedation) within 48 hours of the receipt of the referral. Parkway Clinic provides the Health Board with monthly activity information. Data collected for the first quarter of 2013/14 (April June 2013) has identified an average number of Abertawe Bro Morgannwg University Health Board

33 referrals into the service each month. The graph below breaks down the referrals into age bands and the number of teeth extracted: The following graph breaks down the above information to identify whether or not the referring dentists requested extraction under GA or conscious sedation; it also includes those patients where it was identified that they were being referred for extraction prior to the commencement of orthodontic treatment. The number of referrals requesting that treatment is undertaken under conscious sedation is significantly lower than those requesting treatment under General Anaesthetic. The Health Board has developed in conjunction with Parkway Clinic a revised referral form which will be implemented in October 2013 (Appendix 6A). The new referral form will hopefully provide the Health Board with additional information on the demographics of the 33 Abertawe Bro Morgannwg University Health Board